Abstract: The permissibility of the IUD is a matter of halachic debate. The bleeding that can accompany this method [1][2] is of particular concern in this patient population as it may render the wife niddah and prohibit any physical contact. Timing of insertion or removal so as to minimize niddah may also be of concern to such patients.

Discussion:

Permissibility

There is debate among religious authorities as to the desirability of the IUD, because the exact mechanism of this device is still not completely understood. One possibility is that it prevents implantation [1][3]. Since this is considered by some to be a form of abortion, there are rabbis who forbid this method. Many rabbis, however, permit the use of the IUD because the mechanism of action is more likely to be interference with fertilization rather than implantation [4], and because even preventing implantation would be less problematic at such an early stage of embryonic development [5][A].

There were cases of death associated with the use of the Dalkon Shield [6], which led to the banning of the IUD for a number of years in the United States. Other brands are now available. Nevertheless, preserving health is a serious concern in Jewish law and some rabbis object to this method for medical safety reasons.

Insertion and Removal

A woman should consult with her rabbi to determine if the insertion of an IUD will make her niddah. To prepare for consultation with the rabbi, she needs the following information from her physician: (1) the degree of dilatation (2) if a tenaculum will be used to grasp the cervix, and (3) if bleeding is to be expected from the procedure, and if so for how long. As there is halachic debate about the effects of this procedure on the niddah status, different women may receive different answers from their rabbis. If possible, the rabbi's answer should be taken into consideration in planning the timing of the procedure in order to minimize the time that couple must refrain from physical contact.

The main drawback of the IUD for halacha observant women is its propensity to cause either heavier menses [7] or irregular bleeding [7]. Heavy menses result in additional days of staining before she can begin the process that will enable her to immerse in the mikveh and permit physical contact with her husband. Irregular bleeding can prevent her from successfully completing the count of seven blood-free days, leading to prolonged periods of niddah, or can make her niddah again soon after she has immersed in the mikveh. Women using this method should be advised to wear colored underwear to avoid becoming niddah more than necessary. Some authorities argue that this irregular bleeding should not render her niddah at all, as it is due to the trauma from the device to the uterine lining [C][D]. Most rabbis do not, at present, accept this view [E]. However, when the method is medically appropriate, a woman should be advised to consult her rabbi before abandoning it for halachic reasons.

Some IUD's also release hormones: the Progesterone T releases progesterone and Mirena releases levonorgestrel. These are marketed as causing less bleeding. They do, in fact, result in fewer problems of heavy menses and the resulting anemia [8][9], but produce a friable uterine lining that is more likely to cause staining [8][9]. In addition, since the progesterone incorporated into the device can cause bleeding due to hormonal changes in the lining, even those who view the intermenstrual bleeding from a plain IUD as resulting from trauma would not do so in this case. While this bleeding is reported to decrease over time, the initial months can be very stressful and the couple should be advised that prolonged spotting may accompany the beginning of this method. Some couples may nevertheless prefer hormone-releasing IUD's, as over time the woman is more likely to become amenorrheic [9][10] .They should consult with their rabbi as to strategies to avoid becoming niddah from spotting (e.g. colored undergarments).

One form of the IUD, Gynefix, is imbedded in the uterine wall. There is some evidence in the literature that this may minimize the amount of bleeding [11][12]. There has been some discussion as to whether the insertion site can be viewed as a "wound" to which spotting can be halachically attributed. At present, this is not a clearly accepted position. However, if this method is chosen for medical reasons, the patient's rabbi should be consulted on this point.

Barrier to Immersion

Since the IUD is inserted deeply (inside the uterus), neither it nor the strings that extrude into the vagina are considered a barrier to mikveh immersion[F]. They do not interfere with the performance of the internal self examinations known as bedikot.

Implications for Patient Care:

Prior to scheduling IUD insertion, a woman should contact her rabbi to determine his ruling if insertion will render her niddah. This ruling should be taken into consideration when scheduling the procedure. If it will make her niddah, it is best to schedule for a time that she is niddah anyway. If it will not make her niddah, it is best to schedule for after mikveh immersion that cycle (assuming she is not amenorrheic at the time, e.g., during lactation) so that bleeding from the procedure does not interfere with the internal examinations required before immersion.

Couples should be counseled as to anticipated rates and duration of bleeding from each type of IUD when deciding which method to choose. When staining is anticipated, they should be directed to their rabbi to discuss what halachic precautions can be taken to prevent minimal staining from making a woman niddah more than necessary.

Medical References

[1] Mechanism of action, safety and efficacy of intrauterine devices. Report of a WHO Scientific Group. World Health Organ Tech Rep Ser 1987;753:1.

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